Tissue formation in the root canal

following pulp removal

BI KGEK NYGAARD-OSTBY AND OLAV IIJORTDAL

Dental lnstzfutrz of Experimental Research, Dental Faculty, University of Oslo,

Oslo, Norway

AB,STKACT T h e purpose of this investigation was to elucidate the repair processes in the
root canal after total removal of the pulp. In 47 terth, 35 with vital pulp and 12 with ne-
crotic pulp, the root canal was cleaned and reamed, whereupon a bleeding was induced
and the canal partly filled. I n some teeth there was no bleeding, and these comprised the
control material, which was necessary in deciding whether a blood clot in the root canal
was a condition for repair or would at least enhance the repair processes. T h e observation
periods varied from 9 days to 3 years; a t the end of the period, the tooth was rxtracted or
the root resected with the apical periodontium. Histologic examination of the specimens
revealed that in the teeth with vital pulp, fibrous connective tissue had formed in the root
canal in 28 teeth. Conroniitantly a deposition o f cellular cementum had occurred in many
cases. I n the teeth with necrotic pulp, no repair occurred. T h e clinical implications of the
experimental investigations are discussed.

(Rrceiued for publication 1 3 March, accepted 13 April 1971)

Tissue formations have been observed in iilomatous tissue” invaded the apical fora-
the root canal after the pulp has been men. They seem to have obtained repair
removed and the canal filled with a re- in only one out of 27 experimentally
sorbable material ( ENGEI, 1950, MAT- treatcd teeth in monkeys and human
SUMIYA & KITAMIJRA 1960, STROMBERGheings.
1969, ERAUSQCIN & M U R U Z ~ B1969).
AL Formation of tissue in the root canal
I n a series of expc4niental investigations may be of both general biological and
in dogs and human beings it was found clinical interest, and further studies were
that such formations could take place if therefore carried out in order to assess the
the empty canal was filled only with blood regenerative potential in this area.
from the periapical area (NYCAARD OSTBY
1961) . This was confirmed by ERAIJSQUIN
& MURUZABAI, (1968) who had carried Material and methods
out experiments in rat teeth. MATERIAL
Entirely different results were reported Forty-swen teeth, all in the maxilla, from 1 2 in-
by SELTZER, SOLTANOFF, SINAI,GOLDEN- dividuals were subjected to total pulp removal
BERG & BENDER ( 1968). After “instrumen- and partial root filling. T h e teeth were scheduled
tation beyond the apices of the teeth,” for extraction for prosthetic reasons, and the
patients volunteered to participate in the inves-
they observed that “periapical granulomas tigation.
developed and peraisted” and that “gran- T h e age of the individuals ranged from 18 to
334 NYGAARD-BSTBY AND HJORTDAL
44 years, and the teeth were divided into two
groups according to the state of the pulp: ( 1 )
vital pulp, comprising clinically healthy pulps
and open chronic pulpitis, or ( 2 ) necrotic pulp.
The justification for placing all the teeth with
vital pulp in one group is that all pulp tissue
should be removed, and it was confirmed by an
overall examination of the processed material
that it was unnecessary to distinguish between
clinically healthy pulps and chronic pulpitis.
There were 35 teeth with vital pulp and 12
teeth with necrotic pulp. The latter were all
open to the oral cavity except one with an old
root filling.
METHODS
Endodontic procedures. I n all cases it was
attempted to remove the entire pulp tissue,
vital or necrotic, from the root canal,
which was then partly filled with gutta-
percha points rolled in Kloroperka N - 0
paste, i. e. the apical part was left open and
allowed to fill with blood. In some teeth, which
were to be used as controls, no bleeding was
provoked, and if there was bleeding, it was
stopped. The following medicaments were used:
EDTAC ( V O N DER FEHR& NYGAARD OSTBY
1963) during extirpation and debridement; 30 %
hydrogen peroxide in a few cases to stop the
bleeding from the periapical tissue; and in ne-
crotic cases, 4 % formaldehyde solution as med-
ication. In 30 teeth with vital pulp, extirpa-
tion and root filling were carried out in the
same sitting. In the 12 teeth with necrotic pulp,
debridement and medication were performed in
the usual way. In seven of these teeth culturing ol
samples taken from the root canal before root
filling gave no growth, whereas three teeth were
filled even though bacterial growth was estab-
lished. The bacteriological tests were carried out
as follows: A paper point with a formal-
dehyde solution was sealed in the root canal for
several days. As formaldehyde evaporates in a
short time, a maximum of two days, the point
will, if it is left for a longer time, act as a
sealed-in sterile point. This point was then
delivered directly to the Department of Bar-
teriology, State Institute for Public Health,
where it was cultured in various media.
Histologic procedure. Thirty-seven teeth were
removed by simple extraction, and in 10 cases
the apex was resected surgically together with
the surrounding structures ( NYGAARD BSTBY
1939). The specimens were fixed in 4 % buf-
fered formaldehyde solution and demineralized
in 5.2 % nitric acid. Serial sectioning was car-
ried out, and the sections, 4-5 microns thick,
were stained in hematoxylin-eosin, van Gieson’s,
and Masson’s connective tissue stain.
Histologic evaluation. The result of the treat-
ment was evaluated in each case by examining
all the serial sections through the root canal
and apical foramen.
The findings are summarized in Table 1 for
teeth with vital pulp and Table 2 for the teeth
with necrotic pulp. An explanation of the
system used with reference to the tables is pre-
sented in the following:
I. The tooth is designated by giving its num-
ber from the median line with a “ +” in
front of the numeral if the tooth is on the
left side and behind it if the tooth is on
the right side. Beside the tooth the number
of the last file used is noted. H. stands for
Hedstrom, K. for Kerr.
11. The observation period had to be decided
according to the patient’s request for den-
tures.
111. Under “Canal wall” active cellular resorp-
tion of the canal wall is indicated with a
“-” and deposition of hard tissue on the
wall with a “+”, the number of symbols
indicating the extent of the processes.
IV. Under “Canal content” “ + ” denotes fi-
brous connective tissue and “-” granula-
tion tissue, while “0” means a structure-
less or amorphous mass, which may con-
tain various cells. The number of symbols
indicates the extent of the different parts.
All three of them may be found in the
same canal and then the three different
symbols will appear together. In addition
the length of the new content in the canal
is noted.
V. Under “Root surface” the same symbols
are used as under 111.
VI. Under “Periapical area” “ + ” denotes
fibrous connective tissue, “-” granufa-
tion tissue or larger accumulations of leuko-
cytes. I n addition granulomas and cysts
are recorded.
VII.Under the heading “Remarks” it will be
noted whether any bacterial growth was
registered from the root canal prior to fil-
ling, whether there was no bleeding into
 Table 1
V i t a l pulps

I I1 111 11- I7I 1.11 1'111

Root Periapical
Tooth 0lI.s. ]Jel-iOd Carl'll \*a11 C:arlal ~ ' l ~ l l t ~ l l t C ~ i c g \u ~ Remark:,
\rirfac.e area

1 5 ~ C K.5 9 day.: Blood T None Extraction

2 3 - H.l 1 - t days Blood f Sane. Extraction
3 2; H.3 16 days t 0 i 1.4 Illlll 1 B Extraction
4 2 -I- H.2 2.5 days -0 ( 3 11lIll ) - B Extraction
5 3+ H.5 30 days + - 0 ( 1 . 3 ninii c- B Extraction
6 -4-1 H.3 4f5 days i :- - (2.5 Ill111 I t B Extraction
7 I t H.4 46 day5 -I- -~ 0 ( 6 rnm) t B Extraction
T w o sitting<.
no bleeding,
8 T 3 11.1 52' d 2 y s , I -0 , 2 6 111111, B rrsection.
9 i 1 H.5 60 day5 -c - i1 4 riinil B Extraction
10 + 2 H.3 60 days - T - [ 3 7 Illlll u Kexctiori
11 I t H.l 5 111th t o 0 i 1 6 mm) B Extraction
12 t l H.3 5y' mth Pus G ra n II 1o n la c Extraction
13 + 2 H.3 SJ/j mth t t 0 (3.5 ~ n m ) t B Resection
14 5 + H.l 6 % rritli I- - 0 ( 3 imrn 1 + B Extraction
15 + 3 K.6 6% mth + A - (10 1nm) + B Extraction
16 3 + H.5 7 mth t - (4mm) + B Resection
T w o sittings.
17 2 + H.3 8 nith Pus C n o bleeding,
extraction
Three sittings.
18 I + H.4 811'7 mtli + 0 j 0.7 111111 1 -,- B no bleeding.
extraction
 W
w
0,

Table 1
Vital pulps (continued)

I I1 I11 IV V VI VII VIII

Root Periapical
Tooth Obs. period Canal wall Canal content Category Remarks
surface area

19 + 2 H.3 8v3 mth -- + 0 (2.5 mm) - + B Two sittings,

no bleeding,
resection
20 +2 H.3 8% mth ++ + +-0 (6.7 mm) + Extraction
21 +2 H.3 874mth ++ + + -0 (6.3 mm) - Extraction
22 2+ H.3 9% mth - +- (4mm) - - Extraction
23 +1 H.6 11% mth ++ ++ (5.3 mm) Extraction
24 1+ H.5 11% mth ++ ++ (6mm) + Extraction
0 f 25 1+ H.4 13% mth + + -0 (2.3 mm) + Two sittings,
no bleeding, >
extraction z
16 mth +++ ++0(4mm) + + A Extraction U
3 Yr ++ +++ (8.5 mm) + A Extraction x
i
i
28 1 + H.4 3 Yr +++ (10.5 mm)
+- -+ + + A Extraction
29 + 3 H.5 - - C Extraction
3 Yr
84
30 3 + H.3 - Pus - C No bleeding, U
3 Y'
0 P
extraction r
$3 31 +1 8.2 3 Y' ++ ++- (8.2 mm) ++ B Extraction
32 +3 H.0 3 Yr ++ + + 0 (13 mm) ++ + B Extraction
33 1-2 H.l 3 Y' + (12 mm) + A Extraction
' mm)
+- - +_ +_ +(1.3 +- -
r+
?.-$ 34 2+ H.3 3 Y' Granuloma C N o bleeding,
extraction
35 1 + H.3 3 Y' ++ ++ (7.6 mm) + A Extraction
-
 Table 2
Necrotic pulps

I XI 111 I\’ v L71 \TI1 VIII

Tout11 Obs. period Canal wall Canal content Root Periapical C:atrgol)r Remarks
surface area E
L
3
36 + 2 H.5 35 days I - (1.4 mm) + B Resection, Y

;d
artificial canal.
37 5 + H.4 3y2 mth -0 - C Growth, ?
extraction.
s
n
38 ;2 H.4 4% xnth Pus - c Extraction m
.
cn
39 3 + H.3 4% mth - (0.5 nim) -+ Granuloma C Resection v,
40 + 2 R.2 434 rnth - - - C Extraction m
v,
41 t 5 H.3 5 mth - - 0 12.3 rnrr1’i -t Granulonra C Resection
42 3 + K . l 53/i mth - - - C No bleeding, 2
extraction. 2z
43 + 3 H.4 7y3 nith Granuloma C Growth, no
bleeding, rescction.
Granuloma C Old root filling;
44 t 3 H.5 mth
’2
no sample for cul- 3
turing: no bleeding: c
3
extraction.
45 2 + H.6 10% mth - - - Cyst C N o sample for cul- 2
turing, resection.
46 + 2 H . i 12 mth - Pus - C Extraction
47 + 3 H.7 13 mth - Cyst C Growth, extraction

W
W
-4
338 NYGAARD-6STBY AND H J O R T D A L

the canal during the filling, and whether
extraction or resection was performed. If
there was more than one sitting in the vital
c,ases, this is noted here.
After a n overall evaluation of the findings, each
tooth was classified in one of the following
categories: ( A ) Complete repair. (13) Partial
repair. ( C ) No repair.
organized tissue was found in the root canal.
The content was either granulation tissue,
structureless masses, exudate or pus. When it
was possible to examine the periapical area, a
granuloma or a cyst rould be observed.
Results

A. “Complete repair includes the cases in
which the root canal was filled with fibrous
connective tissue, and any resorption of the
root canal wall had been repaired by depositions
of hard tissue. T h e deposits, usually c,onsisting
of cellular cementum, had sometimes been laid
down in thick layers, thus narrowing the canal
considerably. Very little of the periapical tissue
adhered to the apex when the teeth were ex-
tracted. However, it may he presumed that nor-
mal conditions prevail in the apical periodon-
tium when the main part of the canal contains
fibrous connective tissue. T h e patlern of the
repair process indicated this, and it may be
deduced from the resection cases. NYBORG &
TULLIN (1968) also maintained that the struc-
ture of the tissue in the root canal indicates
the state of the periapical tissue.
B. “Partial repair” comprises the cases in which
the canal contained fibrous tissue apically, some-
times infiltrated with various inflammatory cells.
Coronally to this there was granulation tissue
and occasionally a n amorphous mass with em-
bedded cells, some of which showed degenerative
changes. I n the resection cases the root might
have been cut apically to the level where the
new tissue in the canal ended. Even if only con-
nective tissue was observed, the tooth was
placed in category B because the content of‘
the canal between resection level and root fil-
ling could not be examined.
C. “No repair” includes the cases where no
The results are summarized in Table 1
(vital pulps) and Table 2 (necrotic pulps),
which are explained above. Teeth 1 and
2 were not placed in any category be-
cause their observation periods were too
short. Tooth 3 also had a short observa-
tion period, but the tissue formation was
unmistakable.
There were seven teeth with complete
repair. The connective tissue was well vas-
cularized with fiber bundles running par-
allel to the root canal wall. I n many teeth
dentin fragments were embedded in the
new tissue and surrounded by light zones
indicating deposition of hard tissue,
which had baked the fragments together
or fastened them to the canal wall. Some-
times these deposits contained cells. The
root canal wall usually showed resorption
lines, which had been repaired by hard
tissue, and similar tissue was found in
thick layers on the wall. It contained
cells and resembled crllular cementum.
Tooth 33 (Fig. 1 ) presented the best
result in the entire series. Tooth 26 (Fig.
2 ) is, despite a small amount of amor-
phous mass, placed in this category be-
cause of the well-developed fibrous con-

Fig. 1 . Tooth 33, + 2 a : Radiograph of file in the canal and through the foramen (arrow). b:
Same tooth after 3 years (arrow). A: Section through apical part of the extracted tooth. Foramen
and adjoining root canal empty, probably because pulp was torn during extraction. Fibrous tissue
in rest of the canal with large vessels filled with erythrocytes (arrows). Broad deposits of cellular
cementum on the canal wall ( s ) . B: Lower part of the fibrous tissue, ending against the root fil-
ling (rf), 12 mni from foramen, and containing masses of dentin fragments jdf) embedded in
hard tissue formations. C: Detail from B. Above the root filling ( r f ) fibrous tissue with several
blood vessels ( V ) . Hard tissue deposit on filling material ( h t ). Broad deposit of irregular dentin
on the wall (arrow).
340 NYGAARD-dSTBY AND HJORTDAI,
 REPAIR PROCESSES I N T H E ROOT CANAL 34 1

nective tissue and extensive deposits of
cellular cementum.
Twenty-two teeth showed partial re-
pair, although in one of them it pertained
to an artificial canal made by intentional
root perforation during the reaming. The
length of the fibrous connective tissue.
which was always found apicdlly, varied
as did its structure; sometimes the struc-
ture was dense with only fibroblasts, some-
times looue and infiltrated with macro-
phages and different types of leukocytes,
usually lymphocytes The resorption lines in
the root canal wall were in dlrriost half of
the cases repaired correrponding to the fib-
rous tissue. Coronally to this, there was
granulation tissue, and the root canal wall
showed resorption lacunae Sometime5 the
granulation tissue ended in an aniorphous
mass, which could be fibrin. but which in
teeth observed ovc'r d long period was
difficult to define. I t could contain capil-
laries, leukocytes, f ibroblastq, and pyknotic
cell nuclei. Tooth 21 (Fig. 3 ) and Tooth
15 (Fig. 5 ) are typical of this category.
Tooth 13 (Fig. 5) and Tooth 16 (Fig. 4)
were both resected a t a level above the
root filling. The terth had t o be placed in
this category because an examination of
the entire tissue formation was imposuible.
Tooth 36 (Fig 6a, A ) wns cldssified a5
partidl repair, although this was an artifi-
cial canal, made intentionally during rea-
ming. No attempt had been made to in-
duce repair in the main canal
Sixteen teeth showed n u repair, i. e five
with vital pulp and eleven with necrotic
pulp before the root canal treatment. Thc
canal content varied in appearance: pus
or granulation tissue or just an empty
space. I n the cases where it was possible
to examine the periapical area histologi-
cally, granulomas and cysts were found
(Fig:;. 5C. 6B. 7 ) .
Discussion
Formation of fibrous connective tissue
occurred in 28 out of 35 teeth with vital
pulp, with concomitant deposition of cell-
ular cementum on the root canal wall in
18 twth.
The great variation in the results may
be ascribed to many variables, one of
them being the presence or absence of a
blood clot in the root canal after the
endodontic treatment. Another factor is
the length of the observation time, the
significance of which may be deduced
from the Tables.
The possibility that the bacteriologic
\tatus of the root canal is one of the vari-
ablrs is inconceivable. I t is an established
tact that the root portion of an inflamed
pulp is not infected, even if there is
pulp exposure ( HARNDT1938, MOLLER
1968). This has been confirmed in in-
numerable cases by one of the present
authors, and it is just a matter of tech-
nique and experience to avoid contamina-
tion during the treatment.
The results did not give an unequivocal
answer to the question whether tissue
formation in the root canal is dependent
on a blood clot. The histologic findings,

Fig. 2. Tooth 26, + 1 a: Radiograph o f file in the c m a l (arrow). C: Same tooth after 16 months
(arrow). A: Composite microphotograph of section through the extracted tooth. Fibrous tissue, 4
mm long, in the canal. Broad deposits of cellular cementum on the wall ( s ) . Between root filling
(rf) and canal wall o n both sides, narrow spaces continuing further down (see B and C ) . B: De-
tail of left space containing a n ainorphoiis mass with pyknotic nuclei between root filling (rf) and
canal wall (arrow 1. C: Detail from right space coritainiiig fibrous tissue with capillaries ( v ) close to
root filling (rf ) .
342 NYGAAKD-OSTBY AND HJORTDAI,

Fig. 3. Tooth 21, + 2 a: Radiograph of file in the canal reaching the foramen. b: Same tooth after
834 months. A : Composite microphotograph of section through the extracted tooth. T h e 6.3 mm
long space in the canal filled with fibrous tissue ( 4 rmn) and granulation tissue ( 2 rrirn) ending in
a n amorphous mass against root filling ( r f ) . Artifact ( p ) due to shrinkage. B. Detail from granula-
tion tissue and root filling ( r f ) . Root canal wall to the right ( w ) . Aniorphous mass ( m ) contains
fibrocytes and pyknotic cell nuclei, and a blood vessel ( v ) .
 K E P A l K PRO(:F,SSES IN ' [ H E ROO?' CANAI. :++?I

Fig. 4. 'I'ooth 16, 3 t a : Radiograph o f file in the canal reaching the foramen. 1): Same tooth after
7 riionths (arrow). A: Section through thr resected apcx and apical periodontiurn. Norrnal alveo-
lar bone (k), normal periodontal membrane (pm!. Filxous tissue with dentin fragments (df) in
the canal. Deposits of cellular cenienturri on the root canal wall (arrows). B: Lower part of the re-
sected root canal. Canal contrrit similar to that in A. Lower end of canal filled with debris (x).C:
Rctail of dentin fragrricnts (df j with ce!l-containing hard tissue (kit) embedded in the new fibrous
tissue in the canal.
344 NYGAARD-BSTBY AND HJORTDAL

however, strongly indicate that the pres- blood clot, and the cellular elements
ence of a blood coagulum enhances the are dependent on the diffusion of nutrients
reparative processes. Teeth with and supplied by the tissue fluid. Consequently,
without bleeding prior to the root filling the nutritional conditions will be poorest
have been studied in the same individual in the remotest part of the clot. I n a series
(Table 1 ) . In Teeth 8 and 9, there seemed of experiments on the differentiation of
to be slightly better results in the tooth blood leukocytes and the organization of
where there had been no bleeding, but in blood clots in diffusion chambers, HJORT-
the other cases there was a conspicuous DAL SC RASMUSSEN (1969) and HJORT-
difference in favor of the teeth in which DAL (1970) found the best milieu for cell
there had been a demonstrable bleeding. viability when chambers of small dimen-
There may be objections raised to the sions were used.
use of 30 % hydrogen peroxide as a styptic SELTZER et al. (1968) did not use any
in this connection. I t may be claimed that root filling at all in their experiments, and
it will cauterize the periapical tissue, thus that may, of course, partly account for
impairing its regenerative capacity. This the great discrepancy between the results
conception is refuted by investigations of their experiments and those obtained in
which show that the styptic effect of 30 % the present work. It may, however, also
Hz08 is due to penetration into the tissue be ascribed to other circumstances. In the
of oxygen bubbles which expand and present investigation and in the previous
compress the blood vessels (NORBERG one ( NYGAARD &TBY 1961) the reaming
19311. However, when this effect subsides, of the canal was carefully carried out to
hyperemia ensues, and thus postoperative the radiographic foramen. When debride-
bleeding may create a clot in the canal. ment was deemed accomplished, a file
This may explain the results in Teeth 8, was gently passed through the foramen
18, 19, and 25, which contained a short to ensure bleeding. SELTZER et al. (1968)
plug of connective tissue. Still another ex- described their endodontic procedure as
planation is that coagulated exudate may follows: ‘ I . . . after pulp extirpation, the
have formed a framework for the invading canals were instrumented several millime-
cells. ters beyond the morphologic apices of the
Even if complete repair was achieved teeth. . .”. Their findings of dentin filings
in open canals as long as 12 mm, it is and debris far beyond the apex confirm
logical to assume that it would be ob- the impression that they not only inflicted
tained with greater regularity and within a complicated wound upon the periodon-
a shorter time in a shorter space. Orig- tal membrane and the alveolar bone but
inally there are no capillaries in the also contaminated it with necrotic debris.

Fig. 5. Teeth 12, + l ; 13, + 2 ; and 15, +3. a: Radiograph of the three teeth with files in + 1
and + 2 ( + 3 had been treated earlier and a file had been passed through the foramen). b: Same
teeth 5’/3-6% months later. c: Radiograph of the resected + 2. A: Section through the extracted
+ 3. Upper part of the 10 mm long ingrowth of tissue. Fibrous tissue with some large vessels ( v );
cellular cementum lining the wall (arrows). Normal tissue covering the root surface. B: Section
through the resected + 2. An island of dentin covered with cementum dividing the foramen in two
(i). In the fibrous tissue in the canal a structureless mass (m) with pyknotic cell nuclei. Resorp-
tion lines bordering the canal wall. G: Section through the extracted + 1. Dentin fragments and
pus in the canal. Above the apex a large empty space ( p ) , an artifact, and above this a granuloma.
REPAIR PROCESSES I N T H E ROOT CAN.41, 345
346 NYGAARD-OSTBY AND HJORTDAI,
Under such conditions bleeding into thr
canal cannot bc cxxpected regularly, dnd
no mention i b made b y the authors
whether Mood wa4 present in the canal5
before they were closed. I n thr present
experiments this ha5 always cstablishctl
by a cautious introduction of a papcr
point into the cmal.
However, the clinical iniplicatioris of thr
prewrit and the previous invmtiga tions
( NYGAARI) b s BY~ 1 06 1 require no instru-
mentation beyond the foramen. T h e studies
were meant to elucidate the reparativcx
pro in the root ( anal following pulp
removal and to investigate the feasibilitv
of carrying out a partial pulpc.ctoniy
and root filling in onr sittirig. During par-
tial pulpectomy ( I ~ A V I S1922. NY-
GAARD &,BY 1 93C1, t 944. 1 96 1, KETTERL
1965. NYBOKG& r c u , I N 1965, SELTZER
( t al. 1968 the entire pulp may acci-
dmtally be reniovcd As i t cannot be t*s-
tahlished whether thia hdx happened until
the ancTthesia hds disappeared. this 4hould
necessitatr t w o sittings for the whole Fig. 7. Tooth 34, 2 + : a : Radiograph of file in
proccldurc. However, if thr pulp is torn at t h e canal reaching the foramen (arrow). b:
the apical forarrieti, there will always be d Same tooth 3 years later (arrow!. A : Section
discharge of blood into the root canal. through the extracted 2 + . Loose granulation
tissue in the canal arid a granuloma above the
When it seems likcly that a tissue forma- apex.
tion then will follow. the root filling m a y
be carried out i r i thc first sitting and t o
the point of the supposed severance
None of the tecdi with necrotic pulp the artificial canal. It is difficult to ex-
showcd a n y repair. except Tooth 36 with plain thc gwat difference brtween these

Fia. 6. 'I'eeth 36. + 2 ; and 3 0 . 3 + a : Radiograph of filr in Tooth 36. + 2, showing perforation
of the root. A : Composite rnicrophotograph of section through the false canal. Noi-nial alveolar
bonc ( k ) . 'The fibrous periodontal rnembrane is infiltrated with lymphocytes. At the foramen,
narrow zones of prec'errieniurri ( a r r o w s ) . In the 1.4.nini long false canal, fibrous tissue with
lyniphocytes. I n the main canal below, granulation tissue with numerous blood vessels, leukocytes
and rnacrophagrs. b: Kadiogr,tph of 'I'ooth 39, 3 -L , with a large radiolucency ( a r r o w ) . r : Tooth
39. 3 + , 4yi months later ( a r r o w ) . Marked dinrinishirrc of radiolucency. d: Kesecred root end
and alvrolar bone of Tooth 39, 3 + , radiograph fronr vestibular side (left) and from lateral side
( r i q h t i. 13: Section throiigh the resected root end. :\ccumulation of leukocytes a l o ~ i gthe left canal
wall i a r r o v ) above the root filling ( r f ) . Grannlation tiarur. in foramen, with strands of epithelial
cells ( e ) . .4bovr the apex narrow zones o f 1 0 0 s ~tissur with cell infiltrations, and oiitsidc these a
broad zone of dense fibrous tissue ( f i and ( t o p rishti part of the newly formed borie ( k ) .
348 NYGAARD-OSlBY AND H JORTDAL

results and those in vital cases. The Dres- Acknowledgments - The authors wish to express
ence of microorganisms in the canal might their gratitude to Professor, Dr. odont. EIGIL
AAS, Chairman, Department of Oral Surgery
be one reason for the failure to obtain tis- and Oral Medicine, where the rlinical work
sue formation. The dense accumulation of was carried out; to Research Associate E. CHRIS-
leukocytes along the root canal wall in TIANSEN, State Institute for Public Health, who
Tooth 39 gives a strong indication of in- was responsible for the bacteriological part of
fection. However, the teeth with no the study; and to Miss ASNEVINJEand Miss
GRETHEBERGAUST, Dental Institute of Experi-
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